Lack of belief in long COVID in NZ? / lack of awareness of long COVID?.

Through recent communications with members of the “New Zealand COVID longhaulers” Facebook group, a common theme in New Zealand is a lack of awareness of the condition and a lack of belief that a condition exists.  Through interactions with health professionals and general public the group has found that the common attitude is ‘Covid hasn’t been a problem here, so long Covid isn’t a problem’ (11).  Echoing this sentiment, I recently had a GP registrar who was observing our clinic, and I started a conversation around long COVID. The GP had not heard of the condition, and furthermore, the GP registrar was surprised that physiotherapy assessment and management would be useful in the rehabilitation of these patients.   Therefore, it is essential that patients and therapist are encouraged to educate fellow health practitioners and the public, and help to connect patients with online support groups and community around long-COVID.  Physiotherapy has further roles in support, education, and awareness of Long-COVID (11). 

 

Prevalence

In New Zealand, no specific research of long COVID cases in NZ is currently published, however there may be approximately 250 to 300 people suffering from Long COVID in New Zealand.  This number is supported somewhat by the 237 members of the Facebook group “New Zealand COVID Longhaulers” and by Dr Anna Brooks (Immunologist at Auckland University) which estimate the total to 300+ cases (3, 11).  It is clear however, this group of patients will grow locally and internationally, as Covid-19 case numbers increase.

 

Symptoms of Long COVID

For patients with long COVID symptoms can be diverse and episodic and can commonly include: fatigue and exhaustion, post exertional malaise, chest tightness and pain, shortness of breath, headache, sweats, brain fog and cognitive impairment (1, 2).  There is known involvement of COVID-19 and long COVID impacting through multiple body systems including cardiac, respiratory, renal, endocrine, and neurological system, and this has implications for continued symptoms screening and clinical assessment through time (7,8,11). Care should therefore be taken when managing clients with long COVID due to the possibility of ongoing or late organ damage (7, 8).  Therefore, clinicians must be prepared to halt and seek further investigations if there is any concern around abnormal symptoms.  

 

Abnormal oxygen desaturation and/or Breathing Dysfunction. 

As COVID-19 is initially a respiratory illness there has been significant awareness that oxygen desaturation may occur in the acute phases of the disease, however some patients may also continue to desaturate with activity once they have recovered from the acute phase of the infection.  In these cases, it is necessary to follow up with further specialist assessment.  A further possible diagnosis of hyperventilation and breathing pattern disorders may be present, and therefore referral to a breathing pattern disorder clinic or hospital physiotherapy service is warranted in these cases (1, 10).  Clinically, breathing retraining seems to be a logical and gentle starting point for rehabilitation in this patient group.

 

Autonomic dysfunction - POTS and Orthostatic intolerance.

Orthostatic intolerances and postural orthostatic tachycardia syndrome (POTS) among people with Long COVID (9).  However, clinically it can be difficult to establish a specialist diagnosis of POTS and it may require patients to keep a HR and BP log to capture these changes on a day-to-day basis.  Autonomic conditioning therapy has been described as a possible treatment for long COVID and anecdotally this seems to work well with the limited number of clients we have seen in clinic.

 

Role of physiotherapy in rehabilitation

Physiotherapy has a significant role to play in the rehabilitation of Long COVID, and the World Physiotherapy Briefing paper has done a great job in highlighting the information that is know so far in guiding rehabilitation in this complex condition.  However as stated earlier standard physiotherapy rehabilitation approaches may exacerbated post exertional fatigue. Therefore, it is essential that physiotherapists are educated on this possibility and ask patients about the history of post exertional symptom.  Does the client feel fatigued if they push themselves? Do they experience other symptoms such as breathlessness, chest pain, orthostatic intolerance, and fluctuation in heart rate?  The use of questionnaires can be helpful in identifying how frequent and severe post exertion symptom exacerbation and guidance is that the DePaul Post Exertional Malaise Questionnaire or a short form of this questionnaire (1, 4, 5). Rehabilitation principles of the management of CFS and ME such as “Stop/ Rest/ Pace” and HR monitoring has been also found to be very useful in Long COVID rehabilitation also (6).  

 

Summary:

Long COVID is a complex condition that must be approached with caution and education is essential for physiotherapist, patients, and other health professional.  Extreme caution is required when applying traditional rehabilitation approaches to this complex patient group.

 

Further learning directions:

Long COVID Physio https://longcovid.physio/ 

 

Online course on the assessment and management of Long-COVID https://bradcliffbreathingmethod.thinkific.com/courses/long-covid-19 

 

World Physiotherapy Long COVID Briefing paper 

https://world.physio/covid-19-information-hub/covid-19-briefing-papers 

 

 

Scott Peirce, (Physiotherapist), MHSc, BHSc, PGCert.

Breathing Works, BradCliff Breathing Method.

 

 

 

References

 (1). World Physiotherapy. World Physiotherapy Response to COVID-19 Briefing Paper 9. Safe rehabilitation approaches for people living with Long COVID: physical activity and exercise. London, UK: World Physiotherapy; 2021.

 

 (2). Logue JK, Franko NM, McCulloch DJ, et al. Sequelae in Adults at 6 Months After COVID-19 Infection. JAMA Netw Open. 2021;4(2):e210830. doi:10.1001/jamanetworkopen.2021.0830  

 

 (3).https://www.sciencemediacentre.co.nz/2021/04/29/long-covid-in-new-zealand-expert-qa/ Dr Anna Brooks

 

 (4).Jason LA, Holtzman CS, Sunnquist M, Cotler J. The development of an instrument to assess postexertional malaise in patients with myalgic encephalomyelitis and chronic fatigue syndrome. J Health Psychol. 2021;26(2):238-48. https://journals.sagepub.com/doi/10.1177/1359105318805819?url_ver=Z39.882003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed&.  

 

 

 (5).Cotler J, Holtzman C, Dudun C, Jason LA. A Brief Questionnaire to Assess Post-Exertional Malaise.

Diagnostics (Basel). 2018;8(3):66. https://www.ncbi.nlm.nih.gov/pubmed/30208578. 

 

 

 (6).Décary S, Gaboury I, Poirier S, Garcia C, Simpson S, Bull M, et al. Humility and Acceptance: Working

Within Our Limits With Long COVID and Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. JOSPT.

2021;51(5):197. https://www.jospt.org/doi/10.2519/jospt.2021.0106.

 

 

 (7).Long COVID guidelines need to reflect lived experience, Gorna R et al 2021, Lancet.   :https://doi.org/10.1016/S0140-6736(20)32705-7

 

 

 (8). Dennis A, Wamil M, Alberts J, Oben J, Cuthbertson DJ, Wootton D, et al. Multiorgan impairment in low risk individuals with post-COVID-19 syndrome: a prospective, community-based study. BMJ Open.

2021;11(3):e048391. https://www.ncbi.nlm.nih.gov/pubmed/33785495

 

 

 (9). Postural orthostatic tachycardia syndrome (POTS) and other autonomic disorders after COVID19 infection: a case series of 20 patients. Blitshteyn & Whitelaw. 2021 Immunologic Research https://doi.org/10.1007/s12026-021-09185-5 

 

 

 (10). Motiejunaite J, Balagny P, Arnoult F, Mangin L, Bancal C, d'Ortho MP, et al. Hyperventilation: A Possible Explanation for Long-Lasting Exercise Intolerance in Mild COVID-19 Survivors? Front Physiol.

2020;11:614590. https://www.frontiersin.org/articles/10.3389/fphys.2020.614590/full. 

 

 

(11). Personal communication 13.7.21 with patient at breathing works via email.  Scott Peirce MHSc 

 

 (12). Nalbandian, A., Sehgal, K., Gupta, A. et al. Post-acute COVID-19 syndrome. Nat Med (2021). https://doi.org/10.1038/s41591-021-01283-z